Impact of the Maze Operation Combined With Left-Sided

Valve Surgery on the Change in Tricuspid Regurgitation

Over Time
Hyung-Kwan Kim, MD; Yong-Jin Kim, MD; Kwang-Il Kim, MD; Sang-Ho Jo, MD;
Ki-Bong Kim, MD; Hyuk Ahn, MD; Dae-Won Sohn, MD; Byung-Hee Oh, MD;
Myoung-Mook Lee, MD; Young-Bae Park, MD; Yun-Shik Choi, MD

Background—Atrial fibrillation (AF) has been reported to be a predisposing factor for the progression of TR in patients
with previous mitral or combined mitral/aortic valve surgery. We hypothesized that the maze operation (MAZE) can
prevent the progression of tricuspid regurgitation (TR) in these patients.
Methods and Results—We analyzed 170 patients (age, 45.5⫾10.9 years) who had undergone mitral or combined
mitral/aortic valve surgery. On the basis of preoperative rhythm, patients were divided into 3 groups; GrI was composed
of 44 patients with sinus rhythm, GrII of 48 who had undergone MAZE, and GrIII of 78 with AF who had not undergone
MAZE. Echocardiographic examinations were performed before, immediately after, and 92.2⫾17.2 (range, 50 to 131)
months after surgery. Preoperative and immediate postoperative clinical and echocardiographic parameters were similar
among the groups. Insignificant TR at the immediate postoperative examination worsened with time in 7.3% of GrI (3
of 41), 12.8% of GrII (6 of 47), and 38.8% of GrIII (26 of 67) patients at the final examination (P⫽0.63 for GrI versus
GrII, P⫽0.001 for GrI versus GrIII, P⫽0.005 for GrII versus GrIII). The incidence of significant TR at the final
echocardiographic examination was higher in GrIII (39.7%) compared with GrI (9.1%) and GrII (14.6%) (P⫽0.001 for
GrI versus GrIII, P⫽0.005 for GrII versus GrIII), whereas GrI and GrII did not show any difference (P⫽0.63). By
multivariate analysis, the only factor identified to prevent TR progression was the group factor (GrI and GrII versus
GrIII, P⫽0.002 and P⫽0.005, respectively). In a subgroup analysis of GrII according to the presence or absence of atrial
mechanical activity, the absence of atrial mechanical activity was identified as an independent parameter for the
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progression of TR (P⫽0.001).
Conclusions—AF predisposes patients undergoing mitral valve surgery to the progression of TR, which can be prevented
by MAZE. This additional benefit of MAZE is largely dependent on the restoration and maintenance of atrial
mechanical function. (Circulation. 2005;112[suppl I]:I-14–I-19.)
Key Words: fibrillation 䡲 echocardiography 䡲 surgery

T ricuspid regurgitation (TR) is a common finding in

patients undergoing mitral or combined mitral/aortic
valve surgery.1,2 Although TR may decrease gradually after
mitral or combined mitral/aortic valve surgery with reduction
of right ventricular pressure or volume overload, TR does not
always regress after adequate repair of the underlying le-
sions.3,4 TR often progresses late after surgery without
left-sided valvular dysfunction, even after tricuspid annulo-
plasty. Because the persistence or progression of TR badly
affects the long-term mortality and morbidity, the prevention
and management of functional TR are crucial in these
patients.5
Atrial fibrillation (AF), a common arrhythmia in patients
with left-sided valve diseases, has been identified as an
independent predictor of survival.6,7 Although increased mor-
bidity and mortality in patients with AF is attributed mainly
to heart failure or thromboembolism,8 AF itself is recognized
as a factor that predisposes a patient to the progression of
TR,6 which can impair the quality of life and reduce survival.
Since Cox et al9 introduced the maze operation (MAZE)
for the surgical correction of AF, its effectiveness and safety
have been well demonstrated,10 –15 and thus it has been widely
performed in combination with surgery for underlying struc-
tural heart disease. It is hitherto unknown, however, whether
MAZE can prevent late TR long after surgery. In addition,
because it is well established that MAZE does not always
restore atrial mechanical function,13–16 we sought to evaluate
whether the presence of atrial mechanical activity contributes
to the effect of MAZE on the progression of TR. Therefore,
we designed this study to evaluate whether MAZE can

From the Department of Internal Medicine (H.-K.K., Y.-J.K., K.-I.K., S.-H.J., D.-W.S., B.-H.O., M.-M.L., Y.-B.P., Y.-S.C.), and the Department of
Thoracic Surgery (K.-B.K., H.A.), Seoul National University College of Medicine, Seoul, Korea.
Correspondence to Yong-Jin Kim, MD, Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, 28
Yongon-dong, Chongno-gu, Seoul, 110-744, Korea. E-mail kimdamas@snu.ac.kr
© 2005 American Heart Association Inc.
Circulation is available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.104.524496

I-14
 Kim et al Maze Operation and Tricuspid Regurgitation I-15

Figure 1. Preoperative diagnosis accord-

ing to the type and hemodynamic sever-
ity of mitral and aortic valve disease. The
number in parenthesis represents per-
centage. MS indicates mitral stenosis;
MR, mitral regurgitation; AS, aortic ste-
nosis; and AR, aortic regurgitation.

prevent the progression of TR in patients undergoing mitral
or combined mitral/aortic valve surgery, and if so, whether
progression of TR would be affected by the restoration of
atrial mechanical function.
Methods
Study Population
Three hundred twenty four patients were operated on for mitral or
combined mitral/aortic valve disease from January, 1994, to Decem-
ber ,1997. Hospital records were reviewed before enrollment in the
study, and clinical variables including age, sex, hypertension, body
mass index, smoking habit, and diabetes mellitus were investigated.
Patients with documented organic disease in the tricuspid valve,
the absence of either a hospital record or echocardiographic data, or
an implanted pacemaker were excluded. Those who had received
tricuspid valve replacement were also excluded. Using the exclusion
criteria above, 170 patients aged 45.5⫾10.9 years (range, 17 to 69)
were included in the study. On the basis of preoperative rhythm, 44
patients were allocated to the sinus rhythm group (GrI) and 126 to
the AF group. The AF group was further divided into patients with
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preoperative and postoperative variables within each group, we used
the paired t test or the Mann-Whiney U test.
Multiple logistic regression analysis using the forward stepwise
selection process, including all significant parameters by univariate
analysis and previously known confounding variables, was under-
taken to determine which clinical and echocardiographic parameters
were independently associated with the presence of significant TR
long after surgery. SPSS 11.0 (SPSS Inc) was used for the statistical
analyses and a probability value of ⬍0.05 was considered statisti-
cally significant.
Results
General Features
All 170 patients were followed-up for an average of
92.2⫾17.2 (range, 50 to 131) months. Follow-up durations
were not different for the 3 groups (91.9⫾17.4 in GrI,
88.3⫾13.5 in GrII, and 95.2⫾18.8 in GrIII; P⫽0.09). Preop-
erative diagnosis in the 170 patients according to the type and
hemodynamic severity of valve disease is shown in Figure 1.

(GrII, n⫽48) and without (GrIII, n⫽78) combined MAZE (Cox III Tricuspid valve annuloplasty (De Vega type in 30 patients,
type). During follow-up, sinus conversion occurred in 7 patients with Kay type in 2 patients) was carried out in 32 patients (3
preoperative AF without undergoing MAZE, and these patients were patients in GrI, 11 in GrII, and 18 in GrIII). Of the 170 study
subsequently included in GrIII. On the other hand, AF developed in
patients, 4 underwent reoperation for severe TR during the
1 patient with preoperative sinus rhythm. This patient was included
in GrI for analysis. The decision as to whether to perform MAZE follow-up period, all of whom were from GrIII.
was made solely by surgeons’ preference (H.A. and K.B.K.). MAZE The procedures used for underlying valve lesions are
(Cox III type) was performed as described in detail previously.10 shown in Table 1. Mechanical prostheses, especially bileaflet
tilting discs (St Jude bileaflet valve and Carbomedics valve),
Echocardiographic Examinations were used in the majority of patients for both mitral and aortic
Two-dimensional and Doppler echocardiographic examinations
valve surgery. The main clinical characteristics of the 3
were performed in a standard manner using commercially available
echocardiographic devices before and immediately after surgery as a groups are summarized in Table 2. Patient age was slightly
part of routine clinical care. All examinations were recorded on higher in patients from GrII and GrIII than in GrI, and
super-VHS videotape. digoxin was more often prescribed in GrIII than in GrI or
TR was assessed using multiple transthoracic windows, and the GrII. The other clinical parameters were similar in the 3
maximal jet area in any view was used to estimate the regurgitation
grade using the standard color Doppler technique. The grade of groups.
regurgitation was classified and coded as 0 (none), 1 (trivial), 2
(mild), 3 (moderate), 3.5 (moderate to severe), and 4 (severe) in each TABLE 1. Surgical Procedures Used for Correcting Underlying
patient. For statistical analysis, significant TR was defined as more Left-Sided Valve Disease
than mild in degree. TR maximal velocity was obtained from the
continuous-wave Doppler of the TR signal and was used to calculate Group
systolic pulmonary artery pressure (sPAP). Final echocardiographic
examinations were performed in all recruited patients in the fashion GrI GrII GrIII
described above. Right atrial (RA) mechanical activity was deter- Procedure (n⫽44) (n⫽48) (n⫽78) P Value
mined by the presence of late diastolic tricuspid inflow (A wave) in MVR 33 (75) 39 (81.3) 68 (87.2) 0.10
the last follow-up echocardiogram, with a sample volume placed at
the tip of tricuspid valve. Mitral valve repair 7 (15.9) 9 (18.8) 6 (7.9) 0.07
AVR 11 (25) 12 (25%) 29 (37.2) 0.15
Statistical Analysis Aortic valve repair 1 (2.3) 4 (8.3) 0 (0) 0.28
All values are expressed as mean⫾SD or percentages. The compar-
TV annuloplasty 3 (6.8) 11 (22.9) 18 (23.7) 0.02
ative analysis of the 3 groups was done by analysis of variance with
the Sheffé post hoc test for continuous variables, and the ␹2test or Values are presented as n (%). AMVR indicates mitral valve replacement;
Fisher’s exact test was used for categorical variables. To compare AVR, aortic valve replacement; TV, tricuspid valve.
 I-16 Circulation August 30, 2005

TABLE 2. Clinical Characteristics of the 3 Groups

Group

GrI GrII GrIII

(n⫽44) (n⫽48) (n⫽78) P Value
Age, y 40⫾12 46⫾8* 48⫾10† ⬍0.001
BMI, kg/m2 21.5⫾2.7 22.6⫾2.8 21.3⫾2.9 0.09
Male:female 19:25 18:30 29:49 0.79
Diabetes mellitus, n (%) 0 (0) 1 (2.1) 4 (5.1) 0.10
Hypertension, n (%) 4 (9.1) 9 (18.8) 10 (12.8) 0.70
Smoking status, n (%)
Ever smoker 9 (20.5) 8 (17.4) 15 (19.2) 0.85
Never smoker 32 (72.7) 35 (76.1) 58 (74.4)
Unknown 3 (6.8) 3 (6.5) 5 (6.4)
Medications during follow-up, n (%)
ACEIs or ARBs 3 (6.8) 9 (18.8) 19 (24.4) 0.22
␤-blockers 7 (15.9) 7 (14.6) 9 (11.5) 0.32
CCBs 3 (6.8) 7 (14.6) 10 (12.8) 0.97
Diuretics 6 (13.6) 15 (31.3) 22 (28.2) 0.39
Warfarin 37 (84.1) 40 (83.3) 72 (92.3) 0.44
Aspirin 3 (6.8) 3 (6.3) 1 (1.3) 0.39
Digoxin 8 (18.2) 6 (12.5) 48 (61.5)‡ ⬍0.001
Amiodarone 6 (13.6) 10 (20.8) 13 (16.7) 0.88
BMI indicates body mass index; ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angio-
tensin-receptor blockers; CCBs, calcium channel blockers.
*P⬍0.05 vs GrI; †P⬍0.01 vs GrI; ‡P⬍0.001 vs GrI and GrII.
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Echocardiographic Findings Other Than
TR Grade
All preoperative and immediate postoperative echocardio-
graphic parameters were similar in GrII and GrIII. Preoper-
ative left atrial (LA) size was higher in GrIII than in GrI,
which persisted to the immediate postoperative examinations.
At the final examination, left ventricular ejection fraction
(LVEF) was higher and LA size was smaller in GrI than in the
other 2 groups. No significant differences were found regard-
ing LV dimensions between the 3 groups, whereas sPAP was
highest in GrIII, followed by GrII and then GrI. Comparisons
of echocardiographic findings are shown in Table 3.
Change of TR Grade Over Time
Preoperatively, significant TR was found in 12 patients in GrI
(27.3%), 8 in GrII (16.7%), and 26 in GrIII (33.3%) (P⫽0.33
in GrI versus GrII, P⫽0.62 in GrI versus GrIII, and P⫽0.09
in GrII versus GrIII). Immediately after surgery, 3 patients in
GrI (6.8%), 1 in GrII (2.1%), and 11 in GrIII (14.1%) had
significant TR (P⫽0.55 in GrI versus GrII, P⫽0.36 in GrI
versus GrIII, and P⫽0.09 in GrII versus GrIII). At the last
follow-up, significant TR was present in 4 patients in GrI
(9.1%), 7 in GrII (14.6%), and 31 in GrIII (39.7%) (P⫽0.63
in GrI versus GrII, P⫽0.001 in GrI versus GrIII, and
P⫽0.005 in GrII versus GrIII).
The majority of preoperative insignificant TR remained
stable at the immediate postoperative examination (100% for
GrI, 97.5% for GrII, and 96.2% for GrIII). Insignificant TR at
the examination immediately after surgery, however, was
aggravated) at the final examination in 7.3% of GrI (3 of 41),
12.8% of GrII (6 of 47), and 38.8% of GrIII (26 of 67)
(P⫽0.63 in GrI versus GrII, P⫽0.001 in GrI versus GrIII, and

TABLE 3. Comparison of Echocardiographic Data

Preoperative Immediate Postoperative Last Follow-Up

GrI GrII GrIII P Value GrI GrII GrIII P Value GrI GrII GrIII P Value
LVESD,mm 35.0⫾10.8 37.0⫾8.5 35.2⫾8.8 0.53 35.3⫾9.6 32.1⫾6.6 34.5⫾7.8 0.13 30.4⫾8.0 33.8⫾6.3 33.0⫾8.5 0.09
LVEDD,Mm 54.5⫾12.8 53.5⫾9.0 52.5⫾10.0 0.61 50.1⫾8.1 46.9⫾6.4 48.8⫾7.8 0.14 49.5⫾7.7 50.2⫾6.3 50.0⫾7.8 0.91
LVEF,% 57.2⫾9.4 53.4⫾9.3 56.1⫾11.2 0.18 49.9⫾12.5 52.4⫾9.5 49.7⫾13.2 0.44 62.6⫾10.4 54.6⫾9.6* 56.1⫾11.8* 0.001
LA size, mm 51.0⫾10.7 56.8⫾8.4 60.3⫾12.2* ⬍0.001 41.4⫾8.4 46.4⫾7.8 49.1⫾9.3* ⬍0.001 46.6⫾8.7 52.5⫾7.0† 55.4⫾10.5‡ ⬍0.001
TR grade 1.8⫾1.3 1.6⫾0.9 2.1⫾1.1 0.09 1.0⫾0.8 1.1⫾0.6 1.5⫾1.0† 0.008 1.3⫾0.8 1.7⫾0.9 2.3⫾1.1‡§ ⬍0.001
sPAP, mm Hg 42.3⫾32.1 39.5⫾14.4 47.7⫾23.6 0.22 19.2⫾18.0 27.8⫾13.4 29.8⫾19.6† 0.035 25.0⫾12.4 33.3⫾10.1* 41.5⫾12.8‡㛳 ⬍0.001
LVESD indicates left ventricular end-systolic diameter; LVEDD, left ventricular end-diastolic diameter. Other abbreviations as defined in text.
*P⬍0.01 vs GrI; †P⬍0.05 vs GrI; ‡ P⬍0.001 vs GrI; § P⬍0.01 vs GrII; 㛳P⬍0.005 vs GrII.
 Kim et al
P⫽0.005 in GrII versus GrIII; Figure 2). Figure 3 shows
serial changes of TR grade, sPAP, and LA size over time.
Independent Factors Determining Late
Significant TR
To identify independent clinical and echocardiographic fac-
tors for late significant TR, we performed multivariate
analysis using clinical parameters, namely age, sex, presence
of hypertension, presence of diabetes mellitus, smoking
status, digoxin use, warfarin use, amiodarone use, group
factor, tricuspid annuloplasty, and the type of prosthesis, and
echocardiographic parameters, namely the presence of preop-
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erative significant TR, preoperative LVEF, preoperative LA
size, and preoperative sPAP. The only determinant for pre-
venting late significant TR was the group factor (Table 4). In
this model, MAZE was found to reduce the risk of late
significant TR in GrII by 79% compared with GrIII.
Subgroup Analysis According to Atrial Activity
GrII was categorized into 2 subgroups; GrIIa consisted of 38
patients who maintained sinus rhythm with discernible RA
mechanical activity at the last follow-up, whereas the other
group, GrIIb, comprised 10 patients without RA mechanical
activity, who were in AF (5 patients), accelerated junctional
Maze Operation and Tricuspid Regurgitation I-17
Figure 2. Outcome of preoperative TR in
the 3 groups.
rhythm (2 patients), or sinus rhythm (3 patients). No signif-
icant differences were noted between these 2 subgroups in
terms of echocardiographic and clinical parameters except
age (Table 5). Patients in GrIIa had a significantly smaller LA
size preoperatively and lower TR grade at the final follow-up
than those in GrIIb (55.6⫾8.3 mm versus 61.1⫾7.7 mm,
P⫽0.038, and 1.5⫾0.7 versus 2.4⫾1.1, P⫽0.025, respec-
tively). Multivariate logistic regression analysis of age, sex,
diabetes mellitus status, hypertension status, smoking status,
warfarin use, digoxin use, amiodarone use, tricuspid annulo-
plasty, duration of AF, preoperative LVEF, preoperative LA
size, presence of preoperative significant TR, preoperative
sPAP, and the type of prosthesis and subgroup factor (GrIIa
and GrIIb) showed that the subgroup factor (P⫽0.001,
R2⫽0.623) was an independent parameter that has a signifi-
cant impact on late TR.
Discussion
The principal findings of the present study are that (1) AF
affects the worsening of TR over time in patients undergoing
mitral valve surgery, and it can be possibly prevented by
MAZE, and (2) the recovery and maintenance of atrial
mechanical activity are of great value for such a benefit. To
Figure 3. Changes in TR grade, sPAP,
and LA size with time. A shows preoper-
ative evaluation; B, immediate postoper-
ative evaluation; and C, evaluation at the
final follow-up. *P⬍0.05 vs sinus rhythm
group; †P⬍0.001 vs sinus rhythm group;
‡P⬍0.01 vs maze group; §P⬍0.001 vs
sinus rhythm group; ¶P⬍0.01 vs sinus
rhythm group.
 I-18 Circulation August 30, 2005

TABLE 4. Multivariate Logistic Regression Analysis for information regarding the underlying mechanism and risk
Independent Factors for the Development of Late Significant factors for the progression of TR after surgery is scarce,
Tricuspid Regurgitation however. In our study, patients in GrIII demonstrated a higher
Independent Exponential TR grade at the final follow-up than those in the other 2
Factors Coefficient (␤) 95% CI P Value groups, and multivariate analysis confirmed AF as the only
Group independent factor for late significant TR.
GrI 0.150 0.045 to 0.505 0.002
The mechanism of the progression of TR after surgery in
patients with AF is elusive. It has been reported that atrial
GrII 0.211 0.072 to 0.619 0.005
sizes are closely associated with AF20 –22 and that chronic AF
GrIII 1 (Reference) 䡠䡠䡠 䡠䡠䡠 induces mechanical and electrical remodeling of both atria,
CI indicates confidence interval. R 2⫽0.289 for model. leading to further atrial dilatation.23,24 As Vaturi et al20
suggested, RA dilation may induce tricuspid annulus dilation
our knowledge, this is the first study that shows the impact of with resultant TR progression with time. Also, LA dilation is
MAZE on TR progression after mitral valve surgery. frequently associated with an LA pressure elevation, which
can be transmitted backwards passively or trigger pulmonary
AF and Late Tricuspid Regurgitation arteriolar constriction, leading to increased right ventricular
After Surgery afterload and eventually right-sided chamber enlargement
The importance of significant TR in patients with mitral valve that can contribute to the development of late significant TR.
surgery is due to its close relation to morbidity and mortali- Mitral annulus distortion by mitral valve repair or replace-
ty5,6,17,18 irrespective of sPAP and LVEF.18 Moreover, signif- ment is another potential cause of LA pressure increment.25
icant TR can increase morbidity and mortality despite the
adequate correction of underlying valve diseases.19 The Additional Benefits of MAZE Beyond the
Elimination of AF
Cox et al9 introduced MAZE in 1991 as a surgical means of
TABLE 5. Clinical and Preoperative Echocardiographic effectively controlling AF in combination with surgical man-
Parameters in the Subgroups of GrII
agement of mitral valve in patients with mitral valve disease.
Group IIa Group IIb P The procedure involves the creation of a maze by making
(n⫽38) (n⫽10) Value multiple incisions on both atria, thus allowing sinus node
Age, y 45⫾8 53⫾6 0.004 impulse to be conducted to the atrioventricular node without
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BMI, kg/m 2
22.4⫾3.0 23.2⫾2.1 0.41 creating a reentry circuit.26 It has been reported that sinus
Male:female 15:23 3:7 0.58 rhythm is recovered and maintained in approximately 80% of
Diabetes mellitus, n (%) 1 (2.8) 0 (0) 0.59
cases.13,16,27,28 The conventional benefit of MAZE is the
elimination of AF, and it thus prevents subsequent compli-
Hypertension, n (%) 8 (22.2) 1 (10.0) 0.39
cations related to AF, such as heart failure and thromboem-
Smoking status, n (%)
bolism.29 In addition to these conventional benefits of MAZE,
Ever-smoker 7 (19.5) 1 (10.0) 0.97 our study suggests that it can prevent the progression of TR
Never-smoker 27 (75.0) 8 (80.0) after mitral valve surgery. Patients in GrII in our series
Unknown 2 (5.6) 1 (10.0) showed a substantially (79%) reduced risk of late significant
Medications during follow-up, TR compared with patients in GrIII. Risk reduction, however,
n (%) did not reach the extent achieved in GrI (risk reduction of
ACEIs or ARBs 7 (18.4) 2 (20.0) 0.83 85% in GrI versus 79% in GrII), which is likely to be due to
␤-blockers 6 (15.8) 1 (10.0) 0.49 the possible difference in atrial mechanical function between
CCBs 6 (15.8) 1 (10.0) 0.49
the 2 groups. In subgroup analysis of GrII, we also found that the
presence of atrial mechanical activity is a strong protective factor
Diuretics 10 (26.8) 5 (50.0) 0.16
against the progression of TR, which implies that the additional
Warfarin 32 (84.2) 8 (80.0) 0.75
benefit of MAZE stems mainly from the restoration and main-
Aspirin 2 (5.3) 1 (10.0) 0.97 tenance of atrial mechanical function.
Digoxin 4 (10.5) 2 (20.0) 0.78
Amiodarone 7 (18.4) 3 (30.0) 0.71 Limitations
Preoperative echocardiographic Several limitations of the study need to be acknowledged.
parameter First, this study is limited by its retrospective nature. The
LVESD, mm 36.9⫾8.5 37.3⫾9.5 0.97 decision to perform MAZE was not randomized. Because the
LVEDD, mm 53.3⫾8.7 54.4⫾10.7 0.81 decision was entirely dependent on the preference of the 2
surgeons, however, the clinical and echocardiographic vari-
LVEF, % 52.8⫾9.7 55.5⫾7.6 0.36
ables were not significantly different between GrII and GrIII.
LA size, mm 55.6⫾8.3 61.1⫾7.7 0.04
Therefore, we believe that the validity of our findings is
TR grade 1.6⫾0.9 1.8⫾0.8 0.36 unlikely to be altered by the retrospective study design. A
sPAP, mm Hg 38.5⫾14.8 42.9⫾13.3 0.50 prospective, randomized, controlled study is needed to con-
Abbreviations as in Table 2 and Table 3. firm our results. Second, more detailed quantifications of TR
 Kim et al
grade, for example regurgitant fraction and proximal isove-
locity surface area, were not performed. Although such
techniques may be more appropriate and provide an objective
means for evaluating TR severity, the semiquantitative eval-
uation of TR is a widely used method in clinical practice.
Conclusions
Our data demonstrate that AF predisposes patients undergo-
ing mitral or combined mitral/aortic valve surgery to TR
progression, and that this can be possibly prevented by
MAZE largely by the restoration and maintenance of atrial
mechanical function. Prospective, randomized, clinical trials
are warranted to further confirm our findings.
Acknowledgments
The authors gratefully thank Ok-Yi Park, a sonographer in our
echocardiographic laboratory, for her helpful assistance in the
performance of this study.
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